Abstract

Depression during pregnancy and postpartum is a challenging illness to treat. Physicians from different specialties such as family medicine, obstetrics, and psychiatry often find themselves in a dilemma when it comes to diagnosing and treating the illness. The signs and symptoms of pregnancy may mimic the neuro vegetative signs and symptoms of a depressive illness, as a result both the patient as well as the physician are often unaware of the onset and progress the illness. Depression is a serious, but fortunately a treatable illness which can have long lasting traumatic effects on a woman and her family. Therefore, early recognition, diagnosis, and treatment is warranted.

Depression During Pregnancy And Postpartum

Depression is a common illness which will affect 20 percent of all women at some point in their lifetime. The point prevalence among women of childbearing years is 10 percent. The prevalence among pregnant women is between four to ten percent, and during postpartum period it increases to between 10 and 28 percent.(1&2)

Etiology and Diagnosis

The etiology remains illusive, with general consensus upon complex interactions among biological, psychological, and social factors, although for any given individual one factor may be more important. Postpartum depression seems to have biological roots within the rapidly shifting hormonal milieu, however there is no clear evidence that gonadal hormones, cortisol, prolactin, or thyroid hormones are in any way directly linked. (3)

The diagnosis of depression requires a two week period of persistent change in baseline mood with loss of interest and enjoyment in activities. In addition the following must be found; change in sleep, change in appetite, agitation or slowed movement, excessive fatigue, poor concentration, feelings of worthlessness, and thoughts of death.(4) The physical discomfort and irritability of late pregnancy compounds the diagnosis as does the expected sleep disruption postpartum.

Signs and Symptoms

Melancholic depression typically consists of pronounced sadness, early morning wakening, weight loss, and guilt. Although these symptoms can occur during pregnancy and postpartum, clinicians and researchers have observed that intense irritability with anger overshadow sadness.(5) The significant sleep disturbance may be inability to return to sleep after feeding the baby. Pronounced anxiety with panic attacks, feelings of inadequacy, and failure are common. Women are frequently overwhelmed with demands of infant care.(6&7) Unwanted intruding thoughts of harming the baby can be terrifying. Women may keep these obsessional thoughts secret out of shame unless they are specifically asked about them.(8)

The first postpartum month is the highest risk for onset of severe psychiatric illness.(9) Psychotic depression during pregnancy is rare, however in the postpartum depressed women superimposed psychotic illness can sometimes be observed specially when the onset of depression is late in the postpartum period, and secondly if the depression has been left untreated for a few months. It is critical to treat a psychotic depressed women as soon as the diagnosis is made because these are women in whom infanticide is a tragic complication.(10)

Clinical Vignette

Debbie is a 34 year old married woman who was referred to me four months ago by her family doctor. On examination, I found her to be suffering from moderate to severe degree of depression. She told me that she was feeling depressed with all the classical signs and symptoms three weeks after the birth of her baby. She also described onset of panic attacks about the same time, which eventually took her to see her family doctor. She told me that at first she was very embarrassed to talk to her family doctor about the depression. She felt terrified of the continuous panic attacks she experienced. The complicating thoughts of obsessions to harm the newborn baby made her life a total nightmare.

I interviewed Debbie and her husband together and they did bring the infant with them. Debbie told me that every time she looked at the infant, she had thoughts of pushing the infant from the balcony of their home. Whenever she saw a knife she thought she might accidentally stab her baby with it. These obsessional thoughts preoccupied her mind from the time she woke up until she went to bed. She confided these thoughts finally to her mother who told her that she herself had a postpartum depression after Debbie's birth. Although she felt somewhat validated and relieved by this information, the obsessional thoughts and the panic attacks continued. Debbie became desperate to seek psychiatric help.

Suicidality and Depressive Illness

Thoughts of suicide are frequent, however pregnant and postpartum women rarely commit suicide. The two exceptions to this are women who experience stillbirth and adolescents in whom the suicide risk is significantly elevated. When these women do kill themselves, they tend to use violent means.

Clinical Vignette

Rosie had a stillbirth after years of being infertile. Six months later, she got pregnant again and the second pregnancy tragically ended in early rupture of membranes and consequent death of the newborn. She did not seek any grief counselling with both these losses. After the birth of the second baby, she developed severe depression that concerned her husband a great deal, but he felt this was a "temporary situation" that his wife was experiencing and did not disclose it to the family doctor. One day upon returning from the office, he found Rosie in a state of coma having taken an overdose of several of the medicines at home. Rosie was treated in the hospital and stayed in the inpatient unit for one month. Following her discharge, I had the opportunity of seeing Rosie in my office for psychiatric evaluation.

Rosie's suicide attempt was a serious one. She told me that she really wanted to end her life because she felt a life without children was not worth living. Having lost two pregnancies, she felt completely hopeless. She came from a large family of seven siblings, and each one of the siblings had children. She felt angry, resentful, and continued to have suicidal ideation for several weeks before she responded to treatment.

Risks Factors

Risks factors sited for depression during pregnancy include a previous termination of a pregnancy, bereavement during pregnancy, and a previous personal history of depression.11 Risks factors for postpartum depression include a personal and family history of depression, marital problems during pregnancy, and excessive lability of mood during pregnancy.(12) There is conflicting evidence as to whether obstetrical complications other than stillbirth are significant risk factors.(13) The common transient baby blue syndrome of tearfulness and anxiety during the first ten postpartum days can also be a risk factor for depression.(14) These women should be monitored carefully on a weekly basis for at least six weeks to rule out an impending depression.

Clinical Vignette

Joan is a 26 year old secretary who had an uneventful pregnancy and childbirth two years ago. She recalled enjoying the pregnancy and told me that the postpartum period was relatively smooth. She did not suffer from symptoms of postpartum blues. However after the birth of her second child, she began feeling tearful and started to feel anxious, and experienced insomnia in the hospital. Because it was generally presumed that she was going through the postpartum blues not much was done about it, in terms of treatment. The symptoms increased gradually in severity, and by the time she went to see her family doctor around the sixth postpartum week, she was experiencing early morning wakening, continuously sad mood, excessive tearfulness and complete loss of appetite. Slowly she could no longer do any housework and started to have occasional thoughts of ending her life. Her family doctor who has been treating her mother for a depressive illness made the diagnosis of a postpartum depression, and a referral was made to me for management of this patient.

Other Related Factors

An important psychosocial finding is that marital conflict is common among pregnant and postpartum depressed women. The conflict often antedates depression and if not specifically addressed, it may continue for years after the depression has resolved.(15) Postpartum depressed women tend to experience more negative life events between delivery and onset of depression than nondepressed controls.(15)

In general any one episode of depression is self limiting, but without treatment symptoms can persist for longer than one year. In general population only 25 percent of depression is appropriately treated. During pregnancy and postpartum, depression is commonly misdiagnosed as an adjustment problem implying a transient benign course.(16)

Clinical Vignette

A 31 year old accountant's wife seen in my office recently, started the interview with "I cannot cope with twins anymore". She gave me a history of marital difficulties which had gone on for four years. The couple seeked some marital therapy and thought that having children in their lives would improve their marriage. When she became pregnant with twins, she was pleasantly surprised but concerned and fearful of the effects of two additional members to a household which was described by her as "stormy even at best of times". After she came home with the twins, although her mother helped her for about two weeks, she began to experience a sense of being a failure. She could not keep the house clean, and felt overwhelmed by the amount of laundry she had to do every day. She was in the midst of renovating their house when she became pregnant, consequently the renovations were not completed and she felt she was imprisoned in the house surrounded by packed boxes, cartons, and piles of dust. Because of ongoing marital problems, her husband was not very supportive. He became increasingly distant and angry at her until the communication between the two stopped completely. His work schedule did not allow him to help her with the babies at night. After having sleepless nights for many weeks, she finally collapsed and cried in her doctor's office. At first the doctor also thought that she was responding to the overwhelming stress of the move, birth of the twins, and an unsupportive husband. However the family physician continued to see her on a weekly basis and realized that the patient was battling a major depression. Had she not been followed carefully her depression would have been overlooked as an adjustment disorder.

Complications of Depression

The reasons to treat depression includes humane relief from distressing symptoms as well as facilitate good mothering. Depressed women are more uncertain about their mothering skills, do not fully enjoy their children, and display negative attitude toward their babies. Children of these mother have higher rates of emotional disturbances and demonstrate some cognitive deficit as late as age four.(17&18) Depressed women are at risk for neglecting prenatal care including diet, and preexisting physical problems. Needless to say, suicide and homicide are possible tragic outcomes of untreated depression.

As discussed before, depression can cause significant conflict in marital and family relationships. It can in fact have an impact on employment, education, self esteem, and effect the women's life long after the symptoms are resolved.

Early Intervention

Several studies suggest depression is often not diagnosed when it should be because symptoms are normalized both by patients and doctors as extended baby blues. Other reasons include shame about having these feelings during what is viewed as joyful time, a sociological view of depression as secondary to adaption to the motherhood, and focus on the baby rather than the mother.(3) An important barrier to diagnosis is depressed women's ability to evaluate herself. She often does not reliably volunteer her symptoms and must be asked about them. Routine enquiry about mood during pregnancy and postpartum would improve early detection. In higher risk women warning signs of depression include panic attacks, hopelessness, obsessional thinking, and a daily pattern of depressed mood, which is worse in the morning.(19)

Treatment of Depression

Treatment of depression during pregnancy and postpartum involves a combined approach which consists of biological and psychosocial treatment. Pharmacological intervention of a pregnant and breastfeeding women require a careful assessment and consideration of possible effects on the child. Seriously ill mothers should not be deprived of this treatment. Recent research on the subject of teratogenecity reveal that tricyclic antidepressants can be used during pregnancy provided caution is exercised.(20) Very small amounts of antidepressants are detected in breast milk with no adverse short term consequences to the baby.(21) However, long term neuro behavioral effects of these medicines is unknown and continue to be investigated. Newer classes of antidepressants specifically the selective serotonin reuptake inhibitors have not yet been studied sufficiently to advise their use in pregnancy and lactation. A recent study on fluoxetine did not uncover any increased risk of malformation.(22)

Psychological treatments include a variety of psychotherapies focused on support, education, and resolution of immediate conflict. Including the partner is invaluable both in assessing and intervening in marital problems. Many women find that involvement in self help groups reduces their sense of isolation and provides access to practical advice. It is important for the woman to organize respite from child care, medical leave from work, and time for reliable rest period. Obvious as they may seem, these helpful measures should not be overlooked.

Depression tends to be a recurrent illness. Forty percent of women who have a first episode postpartum will have episodes unrelated to childbearing. The risk of recurrence with a subsequent pregnancy is 20 percent.(23) Women with strictly postpartum episodes may have a better prognosis than those women with episodes outside pregnancy and postpartum.(3)

Specifics About Childbirth Related Depression

Whether depression related to pregnancy and postpartum is distinct from major depressive illness remains unclear. The prevalence is roughly the same for all women in childbearing years. There are no unique symptoms in pregnancy related depression, however clinicians have observed that anger, high anxiety, and obsessions are common. Although the natural history often unfolds to include episodes unrelated to pregnancy, there may be a subgroup of women who have strictly pregnancy related episodes. Research to define such subgroup is ongoing (3).

Conclusion

Psychiatric illness during pregnancy and postpartum demands clear communication between the care givers, the patient, and her family. Everyone involved should be aware of the goals of the treatment and the rational. The patient and her partner should be educated about the risks versus benefits specifically, when pharmacotherapy is indicated. Psychological treatment includes supportive therapy aimed at relieving the symptoms of fear and impending sense of doom and gloom. This unique population of patients is often difficult, but nonetheless, immensely gratifying to treat.

References

1. Wisner KL, Wheeler SB. Prevention of recurrent postpartum major depression. Hosp Community Psychiatry 1994; 45:1191-96.

2. Zuckerman B, Amaro H, Baucher H, Cabral H. Depressive symptoms during pregnancy: relationship to poor health behaviour. Am J Obstet Gynecol 1989; 160:1170-81.

3. Stenier M. Postpartum psychiatric disorders. Can J Psychiatry 1990; 35:89-95.

4. Diagnosis & Statistical Manual of Mental Disorders Fourth Edition, Washington DC, American Psychiatric Association, 1994.

5. Murray L. The impact of postnatal depression on infant development. J Child Psychol Psychiatry 1992; 33:543-61.

6. Wolman WL, Chalmers B, Hofmeyer GJ, Nikodem VC. Postpartum depression and companionship in the clinical birth environment: a randomized, controlled study. Am J Obstet Gynecol 1993; 168:1388-93.

7. Cooper PJ, Campbell EA, Day A, Kennerly H, Bond A. Non-Psychotic psychiatric disorder after childbirth. Br J Psychiatry 1988; 152:799-806.

8. Sichel DA, Cohen L, Rosenbaum JF, Driscoll J. Postpartum onset of obsessive-compulsive disorder. Psychosomatics 1993; 34:277-79.

9. Appleby L. Suicide during pregnancy and in the first postnatal year. Br Med J 1991; 302:137-40.

10. Wisner KL, Peindl K, Hanusa BH. Symptomatology of affective and psychotic illnesses related to childbearing. J Affect Disord 1994; 30:77-87.

11. Kumar R, Robson M. A prospective study of emotional disorders in childbearing women. Br J Psychiatry 1984; 144:35-47.

12. Watson JP, Elliott SA, Rugg AJ, Biough DJ. Psychiatric disorders in pregnancy and the first postnatal year. Br J Psychiatry 1984; 144:453-62.

13. Burger J, Horwitz SM, Forsyth BW, Leventhal JM. Leaf PJ. Psychological sequelae of medical complications during pregnancy. Pediatrics 1993; 91:566-71.

14. Heidrich A, Schleyer M, Spingler H, et al. Postpartum blues: relationship between non-protein bound steroid hormones in plasma and postpartum mood changes. J Affect Disord 1994; 30:93-8.

15. O'Hara MW. Social support , life events, and depression during pregnancy and the puerperium. Arch Gen Psychiatry 1986; 43:569-73.

16. Wisner KL, Peindl K, Hanusa BH. Relationship of psychiatric illness to childbearing states: a hospital-based epidemiologic study. J Affect Disord 1993; 28:39-50.

17. Holden JM. Postnatal depression: its nature effects, and identification using the Edinbugh Postnatal Depression Scale. Birth 1991; 18:211-22.

18. Bester ML, Thompson JM. Postnatal depression in a community cohort. Aust NZ J Psychiatry 1994; 28:42-9.

19. Git MJ, Pasnau RO. Psychiatric syndromes linked to reproductive function in women : a review of current knowledge. Am J Psychiatry 1989; 146:1413-22.

20. Miller LJ. Clinical strategies for the use of psychotropic drugs during pregnancy. Psychiatr Med 1991; 9:275-98.

21. Wisner KL, Perel JM, Wheeler SB. Tricyclic dose requirements across pregnancy. Am J Psychiatry 1993; 150:1541-2.

22. Pastuszak A, Schick-Boschetto B, Zuber C, et al. Pregnancy outcome following first trimester exposure to fluoxetine. JAMA 1993; 269:2246-47.

23. Bell AJ, Land NM, Milne S, Hassanyeh F. Long term outcome of postpartum psychiatric illness requiring admission. J Affect Disord 1994; 31:67-70.

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